Central Line Placement

1
Central Line Placement

• Obtaining Femoral Venous Access Annotations (E)

2
Obtaining Femoral Venous Access Annotations (E)

• Operator gown, glove and mask.
• Risks
• Common--cannulation of femoral artery, line
  infection.
• Rare--injury to femoral nerve, entry into
  peritoneal space, retroperitoneal hematoma.
• Other issues difficult to pass SG catheter
  without fluoroscopic guidance from this position
  avoid in patients with known deep venous
  thromboses.
• Benefits
• Can be placed without interrupting chest
  compressions in cardiac arrest
• Hemorrhage can be controlled with compression.
• Cannulation of artery does not require immediate
  removal of catheter.

3
Obtaining Femoral Venous Access Annotations (E)

• Positioning/Prepping
• Patient should not be in Trendelenburg ideally,
  should be flat and supine.
• Position patient's leg in slight "frog-leg"
  position to open up inguinal fossa.
• Prep with iodine superiorly to 10 cm above
  inguinal ligament, medially to scrotum or labia
  majora, inferiorly to 15 cm below inguinal
  ligament, laterally to anterior superior iliac
  spine.
• Landmarks and Angle of Insertion Trace the
  inguinal ligament from the pubic tubercule to the
  anterior superior iliac spine. The femoral artery
  lies at the junction of the medial and middle
  thirds of this line. The femoral pulse can be
  palpated just inferior to the ligament. The
  femoral vein lies 1 to 2 cm medial to this. The
  needle should be inserted 2 to 3 cm below the
  inguinal ligament to minimize the risk of
  entering the peritoneal space. (See Figure 1)

4
Obtaining Femoral Venous Access Annotations (E)

• Depth/Angle of Insertion The needle should be
  inserted at a 45 to 60 degree angle (not a
  shallow angle) directed in the sagittal plane. A
  common error is to direct the needle in a line
  perpendicular to the inguinal ligament. This will
  cause the needle to pass medial to the vein. The
  vein is usually at a depth of greater than 2 cm
  in obese patients the needle may need to be
  hubbed in order to obtain access. (See Figure 2)
  The fingers of the opposite hand can be
  positioned to help guide your needle and avoid
  puncturing the artery. Place the second and third
  fingers over the medial aspect of the femoral
  artery. The needle should always point in front
  of these fingers which are positioned over the
  artery in order to avoid or reduce the risk of
  sticking the artery.

5
Obtaining Femoral Venous Access Annotations (E)

• Common Problems/Fixes
• Unable to palpate femoral pulse in a code
  situation. Accept cannulation of either artery or
  vein. If artery is cannulated, infuse fluids and
  or pressors as needed until another access is
  gained or circulation is restored.  Remove
  sheath, holding pressure, when patient more
  stable.
• Unable to locate vein. Try repositioning leg try
  ultrasound move closer to inguinal ligament.
• Strong resistance to passage of needle. Likely
  within the inguinal ligament. Remove needle and
  repeat attempt more caudally.
• Vein entered but unable to pass wire. May be in
  superficial femoral vein or leg may be positioned
  poorly. Reattempt from a slightly different
  angle reposition leg.
• First attempt yields flash but poor blood flow.
  Subsequent attempts yield small amounts of blood
  but no flow upon aspiration. Likely a hematoma
  has been formed and is now being entered with
  subsequent sticks. Try another site or use
  ultrasound.